diabetic foot thongchai pratipanawatr md.. site of diabetic foot ulcers site% toe51 plantar...

Diabetic foot

Thongchai Pratipanawatr MD.

Site of Diabetic foot ulcers

Site %

Toe 51

Plantar metatatarsal and mid foot

28

Dorsum of foot 14

Multiple ulcers 7

Outcome of Diabetic foot ulcers

Outcome %

Reepithelization/primary healing

63

Amputation 24

Death 13

Diabetic foot ulcer

Neuropathic foot ulcer

Ishemic foot ulcer

Mixed ishemic-neuropathic

Neuropathic foot ulcer

Risk factors of foot ulcers

Diabetic neuropathy increases risk of foot ulcer and amputation.

Neuropathy 1.7-folds

Deformity 12-folds

Previous history of ulcer

36-fold

Distal sensory neuropathy

Loss pain, temperature And fine touch sensation burning sensation

Vibration, Position sense, Touch/pressure

Motor: intrinsic muscle

Small fiber

Large fiber

Distal sensory neuropathy

Diagnosis10 gm monofilament: small fiber128 Hz tuning fork: large fiberMotor deformity: large fiber

Sensory neuropathy

Loss of protective sensation5.07 (10 gram) Monofilament

Area of examination

Deformity

Abnormal Foot pressure

Deformity

Claw toesClaw toes

Neuropathic foot ulcer

Loss of sensationDeformityCallous formationCallous ruptureFoot ulcerInfection

Diabetic foot ulcer

Insensitive footInappropriate shoe (too tight)DeformityIschemic foot ulcer

Insensitive foot

Insensitive foot

Insensitive foot examination

Examination Justification

General Inspect for possible ulceration

Sensory Test sensation

Temperature Local temp increase more than 2 C indicates of infection

Shoes Inspect foot ware

Muscle Muscle deformaty

Neuropathic foot ulcer

Loss of sensationDeformityCallous formationCallous ruptureFoot ulcerInfection

Claw toes

DeformityDeformity

Hammer toes

DeformityDeformity

21

CallousCallous

22

UlcerUlcer

Chronic ulcer with osteomyelitis

OsteolyticOsteolyticbonebone

Charcot’s foot

Charcot’s foot

Acute Charcot’s foot

Chronic Charcot’s foot

Charcot’s foot

Chacort’s deformity

Others neuropathic ulcer

Too tight shoe

Too tight shoe

Too tight shoe

Too tight shoe

Too tight shoe

Too tight shoe

Ishemic foot ulcer

Ischemic foot ulcer

Ischemic foot ulcer

Ischemic foot ulcer

Diabetic foot care

Risk factors of foot ulcers

Diabetic neuropathy increases risk of foot ulcer and amputation.

Neuropathy 1.7-folds

Deformity 12-folds

Previous history of ulcer

36-fold

Management category

Risk Sensation Deformity Hx of ulcer

0 Present No No

1 absent No No

2 absent Yes No

3 absent Yes Yes

Management category

Risk Managment

0 Foot clinic one a year; foot education

1 Foot clinic every 6 months, appropriated footwear and soft insole

2 Foot clinic every 3 months, custom-molded orthotic devices

3 Foot clinic every 1-2 months, custom-molded orthotic devices

Foot education

Daily cleaning

Skin & nail care

46

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Appropriated footwear and soft insole

Proper shoes design

Proper shoes &soft insole

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Custom-molded orthotic devices

Soft inserts

Mold insoles

Total contact insole

Foot wear

57

CallousCallous

58

CallousCallous

Diabetic wound care

Depth-ischemia classification

Grade Definition

0 At risk (previous ulcer or neuropathy with deformity

1 Superficial ulcer, no infection

2 Deep ulceration exposing tendon or joint (with or without infection)

3 Extensive ulceration with expose bone or deep infections

Depth classification

Depth-ischemia classification

Depth-ischemia classification

Grade Definition

A Not ischemia

B Ischemia without gangrene

C Partial (forefoot) gangrene of the foot

D Complete foot gangrene

Ischemia classification

Depth-ischemia classification

Depth-ischemia classification

Grade Definition

0 At risk (previous ulcer or neuropathy with deformity

1 Superficial ulcer, no infection

2 Deep ulceration exposing tendon or joint (with or without infection)

3 Extensive ulceration with expose bone or deep infections

Depth classification

Depth-ischemia classification

Grade Intervension

0 Patient education and appropriated foot ware

1 External pressure relief

2 And surgical debridement (antibiotic)

3 And antibiotic; amputaiton may be

Depth classification

Off-loading

Total contact cast (TCC) -gold standardPrefabricated pneumatic walking brace ( Air

cast )Half-shoesCrutches,Walkers and WheelchairsBed rest

Total contact cast

Air cast

Half shoe

Modified/custom shoes/orthoses

Surgical intervenion

DebridementAmputationOsteotomyBone stabilizationTendon tranfer or Tenotomy Achilles tendon lengthening tendonetc.

Depth-ischemia classification

Grade Definition

A Not ischemia

B Ischemia without gangrene

C Partial (forefoot) gangrene of the foot

D Complete foot gangrene

Ischemia classification

Vascular screening♦ Hair loss♦ Color♦ Baked potato skin♦ Capillary filling time♦ Temperature♦ Pulses♦ Ankle brachial index (ABI)

Thank you